Medical Social Consultant (Care Coordinator)

Position Summary

The DSCC Core/Connect Care (Consultant) provides care coordination services to families eligible for these two programs. Under the direction of the regional manager and assistant directors, the position is responsible for knowing and abiding by specific program contractual requirements. The Medical Social Consultant is expected to engage and develop strong partnerships with families through completing comprehensive assessments and person-centered care plans, monthly interactions, and coordination of resources.

Duties & Responsibilities

 Under the direction of the regional manager, performs active care coordination services by completing comprehensive health assessments, identifying families' strengths, and developing a person-centered service and care plan.

 Facilitates 30-day ( or as needed) monitoring of the person-centered care plan, assesses/determines status change, prioritizing unmet needs and location of resources.

 Conduct and document in-person visits at home (every 6 months or as needed) or in other appropriate settings like schools or hospitals.

 Completes consistent and timely documentation (within 48 hours) to ensure compliance case record compliance as established by procedures.

 Join and participate in Medicaid managed care clinical rounds occasionally.

 Join and participate in DSCC multidisciplinary meetings as needed.

 Engage as necessary with the transition of the care team to promote effective discharge planning.

 Educate, support, and connect families with resources for a seamless age transition.

 Provide close collaboration with MCO teams for those participants that are co-managed (e.g., waiver recipients).

 Arrange, lead, and contribute with areas of expertise to multi or interdisciplinary care team meetings with participants’ providers, family members, nursing agencies, or school teams.

 Identify/escalate and facilitate internal team meetings on participants with complex behavioral/social determinants or clinical factors impacting their well-being.

 Identifies critical incidents and collaborates with all involved providers for resolution.

 May take the lead on the management of complex behavioral health individuals until the participant is stabilized or moved to a lower level of care coordination management.

 May manage clinically and socially complex caseload participants resulting from neglect or abuse allegations, illness progression, or caregivers’ hardship.

 Utilize as necessary interpreter language line and accommodation resources based on the university’s Americans with Disability Act (ADA) guidelines, such as American Sign Language (ASL).

 Utilize a culturally – competent approach as guided by the university to support families’ cultural values and traditions.

 Active participation in post-records reviews and completion of recommended remediation within expected timeline.

 Contribute to quality improvement initiatives, including but not limited to attendance at quality huddles and provision of recommendations as needed.

 Assist families and caregivers with the coordination of medical services, required treatments, supplies/equipment, and environmental modifications.

 May support other licensed and unlicensed care coordinators in verifying and interpreting clinical conditions, treatments, mental or behavioral health diagnoses or concerns, guiding priorities on the person-centered care plan, and recommending resources.

 Assists families with private/public health insurance through effective benefits management practices for recipients.

 Identify financial needs and assist with the completion of DSCC financial application, and annual redetermination.

 Competent collection of documentation to support administrative/prior approvals for Core eligible services, and utilization of other resources like gift funds.

 Complies with the University, Division, and Regional Office policies, and procedure